Toronto Notebook: XVI International AIDS Conference

Jackie Judd: This is the last full day of the conference and I know what caught your attention this morning was the epidemiological report on Uganda. How was it?

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Jon Cohen: Yeah, there has been a lot of excitement over the years about Uganda's ability to bring down their prevalence, the percentage of people in the population infected, and Uganda had a horrible explosion in the '80s that did indeed come down. Many people have attributed that drop in part to their aggressive campaign, "No Grazing Campaign" is what it has been called, a behavior change.

Jackie Judd: The ABC program.

Jon Cohen: The ABC program and, in fact, the U.S. government has held this up as a model. Look at what Uganda has done. And the new study was very sobering. It suggested in one district, a very large study over many years, that the prevalence is not going down. It seems to be going up in the incidence, the number of new infections per year. In 40- to 49-year-old men it is steeping increasing over the past five years.

Jackie Judd: Do they know why?

Jon Cohen: They have some ideas but no they don't. I mean, one idea is that people lose their partners and they become widows, or widowers, in this case. There is also, as we all know in every country in the world, older men look for new partners and that happens but that wouldn't have changed over time necessarily. So no, at this point they really don't know why.

Jackie Judd: And can a study for one district really be representative of what is happening across the country?

Jon Cohen: That is a very good point. You have to be careful whenever you extrapolate from one study to an entire country. And the study in that same session from India that showed just the opposite, that in India, this one district study showed that, in fact, there were fewer infected people, a lower prevalence than the government figures suggest, but India has 1 billion people. How do you go from one place to the whole place? Of course you can't.

Uganda, there is a little more security because it is a smaller country. You can be a little more confident then, and it should be an important thing for people to look at in Uganda now, because it underscores a really important point. You can have success against HIV, but you've got to maintain whatever it is that got you that success or the virus is going to take off again. You are never done.

Jackie Judd: A couple of other things that caught your interest today: One an update, something we talked about earlier in the week, and that is the integrase inhibitors.

Jon Cohen: Right. Right now, there are a number of HIV drugs on the market, anti-HIV drugs that hit the virus in different ways. Integrase is a new way to hit the virus, a new battlefront. Merck has the product that is furthest in development and today, in the next hour, they are going to reveal the results from a 24 week study. They earlier revealed results from 10 days into this same study and it is basically holding out. And this is a study in people who have never received anti-HIV drugs before.

Merck had another study showing the drug worked remarkably well in people who failed everything, but this is in people who have never taken anything, and it looks to be holding up. So there is a lot of excitement about the characteristics of this drug and the safety and efficacy look good right now.

Jackie Judd: Has Merck made an announcement about the availability of the drugs?

Jon Cohen: They did. They are doing what is called an expanded access program so people can contact them who are interested in getting the drug early. It hasn't received FDA approval, but many people who have failed every drug, they are dying, they need some hope. This is hope for them that they possibly could get this drug and it might work for them.

Jackie Judd: Is that a significant development for people who can't find drugs that work for them?

Jon Cohen: Yeah. These are called expanded access programs. They have saved a lot of lives. Now the drug might fail or the drug might have some horrible toxicity but, you know, if you are very ill, you will take a chance on something that looks promising because you don't have other options.

Jackie Judd: You also heard today a young woman from Russia speak, Sasha Volgina, an HIV/AIDS activist. What was her message to the conference?

Jon Cohen: Very powerful about how her country isn't helping injecting drug users enough, both in preventing infection and in offering them treatment. This is a pattern seen throughout the world.

I have met with injecting drug use communities in Asia, Latin America, the Caribbean. I have seen it all over the place. What happens is, and this is the case in Russia, we know that science has shown that a package called harm reduction, which is you offer drug substitution like methadone people are familiar with, but there are other drugs, needle exchange programs, counseling, you can stop the spread in injecting drug use populations. I mean, you can bring it down next to nothing. Canada has a very aggressive program in Vancouver that is trying to do this. Well, Russia doesn't allow methadone maintenance programs, and that is what she was hitting on very hard, saying that is a great way to help stop the spread of HIV. Science shows that it works. Why doesn't my government do this?

Jackie Judd: In the pecking order of what groups are most discriminated against in the world of AIDS, IDUs at the top, would you say?

Jon Cohen: Yeah, injecting drug users in most every country I have been to are extremely hard for governments to embrace. It is illegal in most places. They are often connected to crime. They are, yeah, I would say they are the most discriminated against, unless you are a transgender injecting drug user. I think they would be a female also, you know, and put it all in with somebody who is very poor and a criminal, yeah, you start getting right, an incarcerated injecting drug use transgender would probably be the most discriminated against.

Jackie Judd: [LAUGHTER]

Jon Cohen: But yeah, absolutely, as far as a group and what is important is that outside of Africa where there really isn't a lot, in sub-Saharan Africa, there is not a lot of injecting drug use. Outside of there, we have heard estimates that 30-percent of the new injections in the world are injecting drug users.

Jackie Judd: Let's step back for a moment, Jon, and I know you talked to Pedro Kahn today, who is from Latin America. He is the incoming president of the International AIDS Society, which is the sponsoring organization of these conferences. What was his view of how things went this week?

Jon Cohen: Well, we spoke specifically about how things have gone in the talks about Latin America and being that he is from Argentina, it's an issue that is near and dear to his heart and he was just shocked there were so few talks about his region of the world.

Jackie Judd: How could that be?

Jon Cohen: Africa and Asia overshadow Latin America and the Caribbean and there are a lot of talks in U.S. and Europe and wealthy countries that can invest in a lot of studies, but Latin America and the Caribbean just haven't received big talks. In the little rooms, there is stuff happening, but he was very disappointed that there wasn't more.

Jackie Judd: And so he clearly sees Mexico City in 2008 as his opportunity?

Jon Cohen: Yeah, it is going to be all different. Oh yeah, that is going to be the point in time, that Latin America and the Caribbean get on the agenda. Mark my words, if you're going to invest in something, invest in that. [LAUGHTER]

Jackie Judd: Well, let's wrap up Toronto forum.

Jon Cohen: Sure.

Jackie Judd: If every conference has a signature or a moment that, years from now, will be remembered or identified with 2006 Toronto, what is it here?

Jon Cohen: Ironically enough, it is the opening. It is Bill and Melinda Gates coming out and saying we care about this issue, here are our thoughts about this issue and by the way we have $62 billion dollars that we are looking to spend, so, you know, money does talk. They are not just filled with words. They have spent $2 billion already from their foundation on AIDS and this community is listening because they think the Gates' can really help shape things in the way governments and the way non-governmental organizations really. And even these multilaterals like U.N. organizations, they can't do what the Gates can do. The Gates can say, we want to do this, and tomorrow they can do it and everybody here knows that.

Jackie Judd: Okay great spending the week with you, Jon.

Jon Cohen: With you, too, Jackie.

Jackie Judd: Do it in Mexico City.

Jon Cohen: I look forward to it.

Jackie Judd: Talk to you then.

Jon Cohen: Okay.

Jackie Judd: Thank you.

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